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?1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> (Complete in Duplicate) <br /> Date •Issued ---••-------f=------ <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct.and install the work herein described. <br /> This application is made in compliance with County Ordinance No, 549. <br /> JOB ADDRESS AND LOCATION____ _---4 6_....- ----------------------------------------- ----�J� �r <br /> Owner's Name -------------------- Phonen''Q-------- <br /> e� r, <br /> Address - .... a ;�L------------t------------••-----------•--•----•-- - <br /> Contractor's Name------.... -------�_-a----------------; ••- ------------------------ -• -:------.._... Phone...14.3 '/Y <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑l Other Q-' <br /> s �/ I <br /> Number of living units: --------'Number of bedrooms -------- Number of baths -------- Lot size ._ ..___T�._.d_______________________________________ <br /> Water Supply: Public system-[Community system El Private E] Depth to Water Table M*ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No &3'• New Construction: Yes j?, No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.' <br /> Septic Tank: Distance from{nearest wel _--__Dist a e ffom fo `n-ation__.l-d•----- <br /> No. of compartments._._. __,-_.-__....__Size_ `��!-___` At Liquid de th- Capacity <br /> 1? ,� r --------- <br /> p 7 " �'�© <br /> a Dis osal Field- Distance from nearest well..-._--._...____Distance from foundation____________________Distance to nearest lot line._______.__-_____ <br /> ❑ Number of lines-----------------------------------Length of each line-------------- ----------- _Width of trench.-----.--------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Distance to nearest well ---- - ---___Distance from foundation__ d__r.___.-._.Distnce to nearest Q. <br /> ee Number of pits------I_---_-.._:_.__Lining material__-lig <br /> ----_._-.Size: Diameter._.-�-_._.u.-__._.Depth__ ��„ ------------ <br /> . Cesspool: Distance from nearest well____________..__Distance from foundation....................Lining material---------------------------.__.____-- <br /> ❑ Size: Diameter----------------------- - ----------Depth----------- ------------------- ---------Liquid Capacity------------ --------gals. <br /> Privy: Distance from nearest well-------------------------------------_-_---------Distance from nearest building.-___._._------.____________-_---------. <br /> ❑ Distance to nearest lot Eine-------- --------------------------------- ----------------------• Q <br /> i <br /> Remodelin and/or re airinq (describe):------ -- ------- ---------------------- ....­---------------------------------------------------------- <br /> ------- <br /> describe __________ __________.__ <br /> NA &G�__ <br /> ------------------- <br /> •------------------------------------------------------------- <br /> ---•------------------------------- <br /> --••-----•---------------------•--•---------••----•----------------------------------- <br /> ------------------ --------------•-•------------------- --------------------------------------•..--------------- -------------------------------------------------------------- ---------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--- --------- ----- - -------------- ---------------------------------- ---------------------------- --------------------- ---.(Owner and/or Contractor) <br /> BY ° ---• --------------------------------- ------- <br /> (Plot <br /> --- (Title} j <br /> k plan, showing siz .of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ------- -- ----------:---------------------------------------- DATE---------------- --------,i"� ------------------ <br /> REVIEWED <br /> BY------------------------- -------- ------- - = S----------------------------- -------------------- DATE_. .• --- <br /> AlteralNG PERMIT ISSUED_.--••-------------------------- -- ------ ---------------------------------------------------------- DATE------ -:- ---••--------------------- ------------------ �-- • <br /> Al I rations and/or recommendations:--------- ----- ----------------------„--------------------•--------__- <br /> --------------------------------------------------------------- ---------------••------------------------------•------------ ----•-•-------•-•-•----- <br /> -•--------• -- i- <br /> __ <br /> --------- -------- ----- -- �'------------ •-------------------------------- --------------­---------------- <br /> ---------- <br /> ------------------------------------------------------------------------ ----------------------------------------- <br /> FINAL INSPECTION BY:.- -- ---- --- ---- Date--- .," <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Streef 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E3-9 145440 ATWtlon <br />